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INTRODUCTION

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The literature on psychiatric illness in surgical patients is limited and mostly confined to small patient samples within surgical subspecialties. The findings suggest that depression, anxiety, and alcohol use disorders are more prevalent, both pre and postoperatively, than in the general population.1 In addition to pre-existing psychiatric illness, surgery may be further complicated postoperatively by delirium, acute stress disorder, posttraumatic stress disorder, new onset mood disorders, or substance withdrawal.

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Studies suggest that common mood and stress-related disorders may be overlooked in the immediate postsurgical phase.2 Rates of depression in the immediate postoperative period range between 10% and 14%, with rates in trauma patients nearing 40% within 1 to 3 months of surgery.3 Untreated, postsurgical depression impacts subjective quality of life scores that may persist several years following surgery and is commonly associated with poorer surgical outcomes.

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Psychiatry plays an important role in the care of the surgical patient. This chapter reviews the role of the psychiatrist in evaluating patients preoperatively, and in managing depression and associated psychiatric conditions during the postoperative period. Many surgical subspecialties carry unique risks for the development of depression and these are reviewed in greater detail.

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PRESURGICAL CONSIDERATIONS

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The preoperative period is a time when information can be collected about a patient's current and past psychiatric history. For certain types of surgeries such as solid-organ transplantation and bariatric surgery, preoperative psychiatric evaluation is routinely recommended in order to identify psychosocial issues that may affect the postoperative course and outcome. Early identification of depression or other psychiatric conditions allows for adequate treatment. Decisions can also be made about maintaining psychiatric medications prior to surgery, ensuring that psychiatric illnesses are monitored postoperatively, and assessing the adequacy of social support postoperatively.

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Antidepressant use is prevalent in patients undergoing elective surgery. As many as 35% of patients undergoing elective surgeries take antidepressant medications.4 It used to be recommended that patients discontinue antidepressant medications prior to surgery. The selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) impact platelet function, which could affect risk of bleeding. Tricyclic antidepressants have been associated with electrocardiographic changes and vulnerability to arrhythmias during anesthesia. Monoamine oxidase inhibitors raise concern about the risk for adverse effects if combined with sympathomimetic agents, opioids or serotonergic medications during surgery.

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For patients with severe depression, however, discontinuation of antidepressant medications may place them at increased risk for recurrence of their depressive symptoms or for discontinuation syndromes. And recent studies suggest that antidepressants may be safely continued prior to surgery. When the use of SSRIs and SNRIs has been examined in cardiac patients, they have not been shown to increase the risk of bleeding in the perioperative period following CABG surgery.5 Likewise, patients who continued to receive tricyclic and tetracyclic antidepressants prior to surgery had no increased incidence of arrhythmia or hypotension, and had ...

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